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Percutaneous Coronary Intervention and Stenting for the Treatment of Myocardial Muscle Bridges: A Consecutive Case Series
Abstract
BACKGROUND: Myocardial muscle bridging is not uncommon; it is usually asymptomatic and on occasion can be associated with angina or even acute coronary syndrome. Traditionally, percutaneous intervention is not advocated and medical management or cardiac surgery, with unroofing of the bridge, is advised if troublesome symptoms occur. OBJECTIVE: To describe the experience and outcome of percutaneous intervention and stenting of symptomatic myocardial muscle bridges. METHODS: A retrospective analysis of prospectively collected data on all patients with symptomatic muscle bridge who were treated with stent insertion after physiologic and intravascular ultrasound assessment was performed. Follow-up of all patients up to 7 years was documented and repeat angiography was performed in 4 of these patients. RESULTS: Seven patients were identified with muscle bridge who were symptomatic and were managed with maximum medical therapy but remained symptomatic. They all underwent percutaneous procedure with physiologic assessment of the muscle bridge with fractional flow reserve and with intravascular ultrasound, which was also used to optimize the stent procedure. All patients remain well and asymptomatic with follow-up from 2-7 years. Two patients had atypical symptoms and had repeat angiography at 18 and 28 months, respectively, and 2 more patients had a follow-up angiography at 32 and 34 months; all showed patent stents and no evidence of any issues. CONCLUSION: Percutaneous intervention and stent for symptomatic muscle bridges performed with physiological and intracoronary imaging assessment and guidance may be an acceptable management modality for symptomatic MB patients, resulting in a good outcome and potentially sparing patients a highly invasive cardiac surgery.
J INVASIVE CARDIOL 2023;35(4):E169-E178.
Key words: cardiac surgery, coronary artery disease, myocardial muscle bridge, percutaneous coronary intervention, stents
Myocardial muscle bridging (MB) describes a congenital anomaly wherein the mid left anterior descending (LAD) coronary artery takes an intramuscular course, also known as a “tunneled” or “bridged” arterial segment.1 The reported incidence of myocardial bridging varies widely depending on the diagnostic modality. In cadaveric heart dissection, MBs were detected in more than 40% of cases, whereas the reported angiographic incidence rates have typically varied between 0.5%-12%.2-4
MBs have also been found in up to 15% of patients with hypertrophic cardiomyopathy,5 and in approximately one-third of transplanted hearts, probably owing to stiff myocardium.6 MBs may also be recognized by multislice computed tomography coronary angiography, with a reported incidence of around 25%.7-9
The vast majority of MBs are incidental findings and of no clinical significance. However, on occasions MBs can lead to ischemia and symptoms. Several reports have described a clinical correlation of MBs with myocardial ischemia, infarction,10 arrhythmias,11 or sudden death.12 The mechanism of myocardial ischemia in MBs is attributable to systolic compression, delayed diastolic relaxation, and/or concomitant atherosclerosis, rarely in the MB itself but more commonly in the segment proximal to the MB due to hemodynamic disturbances.13 Intravascular ultrasound (IVUS) and intracoronary Doppler wire assessments have also demonstrated that the systolic compression in MB may extend into early and mid-diastole,14,15 which in some cases can lead to ischemia and symptoms.
Management of the symptomatic MB has typically been with antianginal medications or rarely with coronary artery bypass grafting or surgical unroofing of the bridge for refractory severe symptoms. Percutaneous coronary intervention (PCI) with stent implantation and stenting has not been advocated due to a perceived risk of stent compression, fracture, and/or restenosis.
Between 2015 and 2019, we have performed IVUS and physiology-guided PCI with contemporary drug-eluting stent (DES) implantation in 7 consecutive patients with MBs and symptoms refractory to medical therapy. We herein present these cases with medium- to long-term follow-up.
Patient 1. A 51-year-old male patient presented with recurrent angina. His coronary angiogram revealed MB with 70% narrowing in the mid-LAD and otherwise normal epicardial vessels. Physiological functional assessment revealed borderline measurements with a resting full-cycle ratio (RFR) of 0.89 and a fractional flow reserve (FFR) of 0.82. IVUS confirmed the presence of an MB in the mid-LAD with the characteristic radiolucent “half-moon” appearance (Figure 1). Additionally, mild atheroma was present proximal to the tunneled segment (Figure 1). The patient was originally treated medically; however, due to persistent symptoms, the patient was readmitted and underwent PCI. The mid-LAD was implanted with 2 DESs (3.0 x 15 mm and 3.5 x 8 mm) with postdilation, with optimal angiographic results (Figure 1). On this occasion, no FFR study was done and no post stenting was obtained. His symptoms resolved and he remains entirely asymptomatic at 3-year follow-up. He had 1 episode of atypical chest pain 28 months later. Repeat coronary angiography at this time showed patent stents with no in-stent restenosis (Figure 1).
Patient 2. A 57-year-old male patient presented with frequent anginal pain on a background of aggressive primary prevention and antianginal medications. Coronary angiogram demonstrated a non-dominant right coronary artery (RCA), normal left main, normal left circumflex (LCX) artery and mid-LAD MB (Figure 2). Physiological assessment of the LAD revealed instantaneous wave-free ratio (iFR) of 0.88 and FFR of 0.80. IVUS revealed mild calcific atheroma in the tunneled segment. Due to refractory angina, the mid-LAD MB was stented with a 3.0- x 28-mm DES and postdilated with a 3.5-mm non-compliant (NC) balloon with optimal angiographic and IVUS results (Figure 2). Poststent FFR was 0.96. The patient had complete resolution of his symptoms with no angina and good exercise tolerance at recent 12-month follow-up. A repeat coronary angiography 32 months later showed no evidence of in-stent restenosis (Figure 2).
Patient 3. A 50-year-old patient presented with typical exertional angina. Coronary angiography demonstrated a mid-LAD MB. He was initially treated conservatively, but his symptoms persisted despite maximally tolerated antianginal therapy and he was readmitted for invasive ischemia testing and consideration for PCI. Physiological functional testing revealed an RFR value of 0.74 and FFR of 0.70. The LAD MB segment was therefore stented with a 3.0- x 28-mm DES and postdilated with a 3.5-mm NC balloon with optimal angiographic and IVUS result (Figure 3). The RFR value rose to 0.92 and the FFR to 0.93 post PCI. At 12-month follow-up, the patient has had no recurrent symptoms and is angina free. At 18 months post procedure, he developed atypical chest pain. Subsequent coronary angiography showed a widely patent stent in the LAD with no restenosis (Figure 3). His symptoms have subsequently resolved.
Patient 4. A 54-year-old male patient with exertional angina. Coronary angiogram demonstrated an isolated LAD MB and he was treated with optimal medical therapy for a few months. He continued to experience angina and was brought back for invasive ischemia assessment and consideration for PCI. Physiological functional testing demonstrated that the mid-LAD was hemodynamically significant (RFR of 0.81 and FFR 0.75). IVUS confirmed the presence of MB with characteristic lucent “half-moon” appearance (Figure 4). PCI of the mid-LAD MB was performed with 2 DESs (3.0 x 28 mm and 3.0 x 8 mm) and postdilated with a 3.5-mm NC balloon with excellent angiographic and IVUS results (Figure 4). The RFR after angioplasty rose to 0.92 and FFR to 0.94. At over 20 months of follow-up, the patient had no cardiac symptoms. Repeat coronary angiography at 34 months showed patent stents with no evidence of restenosis.
Patients 5-7. A 36-year-old male patient with type I diabetes mellitus, recurrent palpitations, and exertional chest pain underwent coronary angiography showing a mid-LAD MB. He was initially managed medically. However, he remained symptomatic and was referred for further assessment. FFR was 0.77 beyond the MB, consistent with ischemia, with no atherosclerotic disease visible on IVUS. The MB was stented with DES and postdilated. Repeat FFR of 0.94 and IVUS showed well expanded and apposed stent. The PCI was performed in 2015 and he remains asymptomatic now more than 7 years after the procedure. No follow-up coronary angiography was performed, as he remains asymptomatic.
This was our first patient who underwent PCI of an MB. Unfortunately, his angiographic and IVUS images could not be retrieved. Two more patients had similar presentation of effort angina with MBs found in their mid-LAD with positive FFR, prior to stenting, who were also treated with PCI and DES implantation after the first patient in 2016 and 2017, respectively. They both remain asymptomatic at 6-year and 5-year follow-up, respectively. Unfortunately, their images also could not be retrieved.
Discussion
These 7 cases demonstrate successful PCI clinical outcomes after DES treatment of mid-LAD MB in patients with symptoms refractory to medical therapy, with long-term symptom resolution and no clinical or angiographic evidence of restenosis or other stent failure issues. We performed follow-up angiography in 4 of these patients; 2 had atypical symptoms and 2 had no symptoms but underwent imaging due to the nature of MB and the possible issues that can arise with stents.
To date, there are no randomized trials evaluating the optimal treatment strategy for patients with symptomatic MBs. Available management options include medical treatment, stenting of the tunneled segment or surgery (MB un-roofing or bypass grafting). The aim of medical therapy is to prolong diastolic coronary perfusion time through chronotropic reduction and to reduce systolic compression through inotropic reduction.16 Of note, nitrates are contraindicated in patients with MB as they may accentuate the systolic compression by the reflex increase in sympathetic tone and vessel compliance.17
Although the majority of symptomatic MB patients improve with optimal medical treatment, some cases remain symptomatic. In a meta-analysis of 18 studies including 899 patients with MBs, 20% had refractory angina despite optimal medical treatment.18 Surgical myomectomy can un-roof the MB band and is often successful, although still a major operation.19-21 Surgical coronary artery bypass grafting is possible but less attractive due to a high rate of arterial or venous graft occlusion in these patients.22
PCI of the MB is a potentially attractive approach in patients with symptoms refractory to medical therapy given its less invasive nature compared with cardiac surgery. Stenting of the MB is also straightforward given the typical absence of atherosclerotic disease. Prior to the present report, successful MB PCI has been reported in a few case reports.23-25 However, stenting MBs has been controversial due to a theoretical risk of stent fracture or restenosis. Complications—in particular, coronary perforation—have also been reported during or after PCI.26 Other complications, such as stent fracture,27 coronary aneurysm,28 systolic narrowing and in-stent restenosis,29 and iatrogenic fistula30,31 have also been reported. However, MB PCI was performed in these cases without intravascular guidance and using bare-metal stents or first-generation DES.
Some MB cases have atherosclerosis present in the inflow and outflow, which are the high sheer stress sites. The systolic constriction in addition to the atherosclerosis, even a mild degree, combine to lead to symptoms. Stenting would address both pathologies and may help relieve the symptoms.
In the present reported experience, 7 consecutive patients with ischemia and angina refractory to optimal medical therapy due to mid-LAD MBs were treated successfully with contemporary DES implantation. All achieved long-term symptom relief ranging from 1 to 6 years at latest follow-up. Repeat angiography performed in 4 of our patients (2 for transitory atypical chest pain at 18 and 28 months and 2 for follow-up assessment at 32 and 34 months) demonstrated no restenosis, stent fracture, or other stent-related issues, suggesting that PCI with DES may be an effective therapy for selected patients with MBs. These results should be validated in other retrospective and prospective series.
Our improved results compared with prior PCI MB case reports may in part be due to advances in stent technology. In addition, we ensured that the stent is longer than the MB by 3-5 mm distally and proximally. This is to ensure that the points of flexion of the artery are covered, which we believe is important to prevent future problems with the implanted stents.
The current generation of DES has thinner struts and is more malleable and conformable to the vessel shape, while maintaining excellent radial strength.32 If our results are validated in other series, the role for surgical interventions may increasingly be relegated to patients with concomitant multivessel coronary artery or valve disease or those with recurrent symptoms after MB stent restenosis.
We believe that physiologic lesion assessment and intravascular imaging guidance are essential if MBs are to be stented. First, as most MBs are asymptomatic, meticulous assessment of the tunneled segment using non-invasive and invasive physiology is crucial to ensure the presence of ischemia.23,33,34,35 Of note, overshooting intracoronary pressure caused by the bridged segment may lead to underestimation of compression severity, particularly when measured by conventional hyperemic FFR. Therefore, diastolic FFR and dobutamine stress FFR have been recommended to assess MB.33 In this regard, the use of dobutamine rather than adenosine as a stressor agent during FFR increases the sensitivity for the detection of ischemia in MBs, reflecting the role of inotropy in enhancing vessel compression.36 Dynamic vessel obstruction increases the recorded intracoronary pressures above aortic pressure, particularly in the segment proximal to MB.37 Additionally, dobutamine-induced tachycardia and increased cardiac inotropy aggravate the intracoronary physiological changes precipitating myocardial ischemia with adenosine-induced vasodilatation.16
Second, IVUS is extremely useful for MB diagnosis and to guide stent implantation. In conventional coronary angiography, a typical “milking systolic effect” is considered a strong diagnostic indicator of MB.13 However, this sign is not always present. IVUS is significantly more sensitive for the detection of MB than angiographic assessment alone and should be considered when there is any angiographic ambiguity.38 MBs have a characteristic appearance on IVUS, described as an echolucent “half-moon” appearance.39,40 IVUS measurements of the bridged segment often demonstrate smaller vessel area than the unaffected proximal and distal segments.38,40 Frame-by-frame IVUS analysis may demonstrate delayed diastolic relaxation of the tunneled myocardium along with systolic compression.41 Furthermore, IVUS helps to delineate concomitant atherosclerosis and vessel size, which may reduce the incidence of coronary perforation associated with MB PCI.3 We ensure the stent length covers 3-5 mm proximal and distal to the MB, with 1-to-1 sizing of the stent to the reference vessel diameter to ensure that the stent is well anchored and fixed and will not be affected by deflection movement and compression. However, if the MB itself is substantially negatively remodeled, a smaller stent may be necessary (sized to the external elastic membrane diameter in the MB itself rather than the reference segments) to avoid perforation. Post stent implantation, IVUS is useful to ensure that the stent is maximally expanded and apposed to the vessel wall.
Study limitations. This small series, while promising, does not constitute definite evidence and our results should be confirmed by additional registries. Follow-up angiography was performed in 4 of our patients, in each case without late repeat intravascular imaging. While randomized trials for the treatment of MBs are not likely, the establishment of an international multicenter registry consortium may rapidly generate important outcome data.
Conclusion
The present report suggests that symptomatic MBs can successfully be treated with contemporary DES options. Our case series highlights the feasibility and potential safety and effectiveness of PCI guided by physiology and intravascular imaging to provide long-term symptomatic relief to patients with MBs refractory to medical therapy. These outcomes should be confirmed by additional multicenter studies prior to PCI being established as a routine approach for MBs.
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From 1Cardiothoracic Department, Freeman Hospital, Newcastle-Upon-Tyne, United Kingdom; 2Cardiovascular Medicine Department, Faculty of medicine, Tanta University, Egypt; 3The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; 4Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom; 5Sunderland University, School of Medicine, Sunderland, United Kingdom.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
The authors report that patient consent was provided for publication of the images used herein.
Manuscript accepted December 8, 2022.
Address for correspondence: Professor Mohaned Egred, BSc (Hons) MB ChB MD FRCP FESC, Cardiothoracic Department, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN, United Kingdom. Email: m.egred@nhs.net
